Cost Of Services Research Articles

Real-world service costs for neovascular-AMD clinics in the United Kingdom: structured literature review and scenario analysis

Objective Current cost-effectiveness analyses (CEA) emphasize drug costs as the differentiator between NICE recommended anti-VEGF treatments but may neglect real-world non-drug costs of running nAMD services in the UK. To address this, this study identified real-world non-drug service cost items relevant to UK NHS nAMD clinics, including costs arising from operational strain (demand exceeding capacity). Methods Cost items were identified by a structured literature review of peer-reviewed and grey literature, and an expert panel of 10 UK-based ophthalmologists with relevance to real-world practice. These items underwent meta-synthesis and were then determined in a consensus exercise. Results Of 237 cost items identified, 217 (91.6%) met the consensus threshold of >0.51 and were included in the nAMD Service Non-Drug Cost Instrument (nAS). Sensitivity of cost items taken from UK Health Technology Assessment (HTA) using the nAS as the reference standard was low (HTAmin: 1.84%, 95% CI 0.50–4.65%; HTAmax: 70.51%, 95% CI 63.96–76.49%). False negative rates showed variable likelihood of misclassifying a service by cost burden depending on prevalence. Scenario analysis using cost magnitudes estimated annual per-patient clinic cost at £845 (within capacity) to £13,960 (under strain) compared to an HTAmin estimate of £210. Accounting for cost of strain under an assumed 50% increase in health resource utilization influenced cost-effectiveness in a hypothetical genericisation scenario. Conclusion Findings suggested that HTA underestimates UK NHS nAMD clinic cost burden with cost of strain contributing substantial additional unmeasured expense with impact on CEA. Given potential undertreatment due to strain, durability is suggested as one of the relevant factors in CEA of nAMD anti-VEGF treatments due to robustness under limited capacity conditions affecting UK ophthalmology services.

The Economic Efficiency of Android Phone Enabled Modems and Standard Modems in Nigeria: The Case of Abuja

This study examined the economic efficiency of Android phone-enabled modems and standard modems in Nigeria. A sample of 388 commercial (cybercafe) and private internet service users were selected using random sampling. The data were analyzed using frequency and percentage calculations to identify patterns and trends as well as ordinal logit regression analysis. The research study revealed that the odds for higher economic efficiency rise when subscribers or commercial (cybercafe) and private internet service users’ monthly internet subscriptions is lower. Similarly, the study revealed that the odds for higher economic efficiency rise when subscribers or commercial (cybercafe) and private internet service user’s daily internet access time increases. Regarding connectivity issues while using an Android-enabled modem, the study showed that the odds for higher economic efficiency fall when connectivity challenges increase. The odds for higher economic efficiency increase when connectivity challenges arise while using a standard modem. The research study also showed that the odds for higher economic efficiency increases when more expensive Android phones are used. The study further revealed that the odds for higher economic efficiency will fall when subscribers or commercial (cybercafe) and private internet service users use less expensive standard modems. The study also revealed that the effect of the explanatory variables or predictors is different across the levels of the dependent or explained variable. Thus, the study recommends that regulatory agencies and operators should come up with a price per megabyte of internet access that will reduce the initial cost of services rendered by private and commercial internet users in a bid to drive economic growth. Regulators and service providers must ensure minimal or no interference with the service provided to end users in a bid to promote the economic efficiency of Internet services. Efforts must be made by the government to the efficient devices affordable, and an embargo must be placed on the importation of internet devices (phone and standard modem) with poor efficiency

A cost analysis of upscaling access to continuity of midwifery carer: Population-based microsimulation in Queensland, Australia

ObjectiveTo quantify the economic impact of upscaling access to continuity of midwifery carer, compared with current standard maternity care, from the perspective of the public health care system. MethodsWe created a static microsimulation model based on a whole-of-population linked administrative data set containing all public hospital births in one Australian state (Queensland) between July 2017 to June 2018 (n = 37,701). This model was weighted to represent projected State-level births between July 2023 and June 2031. Woman and infant health service costs (inpatient, outpatient and emergency department) during pregnancy and birth were summed. The base model represented current standard maternity care and a counterfactual model represented two hypothetical scenarios where 50% or 65% of women giving birth would access continuity of midwifery carer. Costs were reported in 2021/22 AUD. ResultsThe estimated cost savings to Queensland public hospital funders per pregnancy were $336 in 2023/24 and $546 with 50% access. With 65% access, the cost savings were estimated to be $534 per pregnancy in 2023/24 and $839 in 2030/31. A total State-level annual cost saving of $12 million in 2023/24 and $19 million in 2030/31 was estimated with 50% access. With 65% access, total State-level annual cost savings were estimated to be $19 million in 2023/24 and $30 million in 2030/31. ConclusionEnabling most childbearing women in Australia to access continuity of midwifery carer would realise significant cost savings for the public health care system by reducing the rate of operative birth.

Freeport as a Hub in the Art Market: Shanghai Art Freeport

With the soaring interest in art as an alternative investment approach and an asset class, there has been a remarkable rise in the volume of artwork transactions globally. However, trading in the art market differs from the traditional financial market; the cost of taxes, logistics, storage, and other transaction services is enormous for collectors, stimulating the emergence of related businesses, such as warehousing, bonded exhibitions, and art financial services. As an exceptional area serving the offshore economy, art freeports have become an essential venue for art trading and a ‘one-stop-shop’ centre that converges all art market participants. This article critically analyses the current literature and conducts empirical research on Shanghai FTZ International Culture Investment and Development Co., Ltd. (FTZART). It can be concluded that the current research on art freeports is limited and excludes FTZART from those that specialise in storing artworks, overlooking its potential influence in the Asian market. The art freeport has distinctive features that differ from traditional freeport models, and the context, business model, and operations of FTZART match these characteristics. Therefore, as a hub in the art market, the global art freeport agenda should not overlook FTZART, and it is essential to complement this gap in knowledge.

Opinions regarding equine veterinarian attire and attributes: results of a horse owner survey.

To investigate potential equine clients' perceptions of equine veterinarians based on attire. 763 horse owners/lessees. Participants were invited to complete a survey shared mainly via equestrian social media pages between August and October 2022.1-3 Survey participants were shown pictures of a male veterinarian and a female veterinarian in 7 outfits ranging from casual to business attire and were asked to score the veterinarian on 7 traits: easygoing attitude, friendliness, compassion, trustworthiness, professionalism, competence, and cost of services. The survey asked which of the traits were most valued in an equine veterinarian, as well as whether various aspects of appearance including tattoos, piercings, and hair dyed a nonorganic color were acceptable for equine veterinarians. Of the 2,655 individuals who opened the survey, 763 responses were included. Respondents were predominantly female (743/763 [97.4%]) from rural areas (493/763 [64.6%]). Only 37.1% (283/763) of respondents agreed that what a veterinarian wears influences their confidence in them. The highest-ranked traits in an equine veterinarian were knowledge/competency (mean ± SD, 1.46 ± 0.98), followed by trustworthiness (2.34 ± 1.08) and compassion (3.50 ± 1.20), with coveralls and scrubs being the preferred attire clients associated with these attributes (with the exception of compassion, for which polo shirt/jeans was the preferred attire). T-shirt/jeans was consistently ranked lowest by respondents in association with these attributes, except in the area of compassion, where polo shirt/black pants was ranked lowest. Our findings suggested the attire and appearance of equine veterinarians can impact client perceptions, with veterinarians wearing scrubs and coveralls associated with higher competency and trustworthiness.

PRICE RECALCULATION MODEL OF CONSTRUCTION CONTRACTS

In recent years, the world economy has experienced rapid economic change in the construction sector and record inflation. The rapidly rising prices of construction materials and machinery in the construction market are also pushing up the cost of construction services. The main problem is that construction projects have been drawn up and contracts between clients and contractors have been awarded at previous prices, and it is therefore necessary to look for opportunities to index the price of construction contracts. The aim of the study is to propose a mathematical model and a smartphone application for the price recalculation of construction projects. The success of a construction project depends on the correct decisions taken at the stage of preparation and implementation of the procurement documents for construction contracts, a complex process requiring a lot of legal and technological knowledge. The proposed mathematical model would help clients and contractors to carry out the calculation of the price according to the construction price index quickly and without the need for extensive specialist technical expertise. The mathematical model is adapted to smartphones with Android software.

Working with bloggers as an effective tool for promoting a telecommunication company

The article analyzes the use of bloggers as an effective tool for promoting telecommunications companies on social networks and video hosting sites. The author examines in detail the key advantages of cooperation with influencers, such as increasing brand awareness, significantly expanding the reach of the target audience, increasing sales, increasing consumer engagement and loyalty, as well as improving the company’s image as modern and keeping up with digital trends.The article highlights the potential risks of working with bloggers, including the high cost of popular influencers, the possibility of encountering low–quality blogging sites with fake audiences, the threat of reputational losses, legislative restrictions in the field of advertising certain services and the lack of full control over the content created by the blogger.To minimize risks and increase the effectiveness of collaborations, the author gives detailed recommendations on the selection of suitable bloggers. Among the key criteria are: the correspondence of the blogger’s audience to the company’s target audience, a high level of subscriber engagement, the relevance of content to the brand’s theme, successful experience in advertising integrations, as well as adequate cost of services. Telecommunications companies are advised to use special social media monitoring services to analyze the quality of the audience of influencers.In conclusion, it is emphasized that a systematic approach to planning advertising campaigns with bloggers, constant monitoring of their implementation and a comprehensive assessment of results on a number of qualitative and quantitative indicators will allow telecommunications companies to maximize the benefits of cooperation with influencers and achieve high efficiency of investments in blogger marketing.

Unmet healthcare needs, access to services and experiences with health providers among persons with spinal cord injury in Australia.

Cross-sectional survey. Appropriate and timely lifelong access to healthcare following a spinal cord injury (SCI) is critical, yet unmet healthcare needs in this population are common. Poor experiences with healthcare providers can be a barrier to health-seeking behaviour, and we hypothesised that there would be an association between unmet healthcare needs and care experiences. This study aimed to: (1) describe healthcare provider utilisation in the past year, unmet care needs and satisfaction with healthcare services; (2) explore the association between experiences with healthcare providers and unmet healthcare needs; and (3) explore the association between healthcare provider utilisation and participant characteristics, including unmet healthcare needs. Community. Analysis of data for 1579 Australians aged ≥ 18, who were ≥ 1-year post-SCI and living in the community. Bayesian penalised regression was used to model six binary outcomes: unmet healthcare needs; the use of general practitioners (GPs), allied health practitioners, rehabilitation specialists;medical specialists; and hospitalisations in the past 12-months. Unmet needs were reported by 17% of participants, with service cost the common deterrent. There was evidence of an effect for provider experiences on unmet healthcare needs, but no evidence that unmet healthcare needs was associated with the use of GPs, allied health practitioners, and rehabilitation or medical specialists. Unmet healthcare needs were reported in the context of high healthcare use and large proportions of secondary conditions in a cohort with long-term SCI. Improved health access for people with SCI include better primary-secondary care collaboration is needed.

Direct and indirect costs of paediatric asthma in the UK: a cost analysis

ObjectiveTo estimate the cost of paediatric asthma from a UK National Health Service (NHS) and societal perspective and explore determinants of these costs.DesignCost analysis based on data from a large...

The experiences of patients with COVID-19 and their relatives from receiving professional home care nursing: a qualitative content analysis

BackgroundTo overcome of patients with COVID-19 over the capacity of hospitals and mild to moderate severity of the disease in most cases, the World Health Organization and the Centers for Disease Control and Prevention in the United States, recommend home care for these patients. Receiving care at home will face challenges that can be context-based, especially in crises like the Coronavirus pandemic. The present study aimed to describe the experiences of patients with COVID-19 and their relatives from receiving professional home care nursing.MethodsThis study was conducted using a qualitative content analysis method. Nine participants with COVID-19 who were receiving home care nursing in Semnan participated in this study. The purposive sampling method was used. Sampling continued until no new categories appeared, meaning the category’s theoretical saturation. Deep and semi-structured interviews were used to collect data based on the research question. Data was analyzed using the conventional content analysis method using Graneheim and Lundman’s approach.ResultsAfter analyzing the interviews and comparing codes based on similarities and differences, three main themes, 11 categories, and 30 subcategories were identified. The main themes included “The value of home care” (personalization of care, being economical, providing intellectual security, and reducing the concern of family), “Comprehensive care” (professional commitment, empathy, mastery in care, and patronage), and “Care challenges” (cultural barriers, inadequate services, and lack of information about costs and conditions).ConclusionThe patients with COVID-19 who received professional nursing care at home mentioned some challenges, such as the caregiver not being of the same sex as the patient, delay in receiving the service, the inadequacy of the centers, the limitation of the right to choose the care provider, and insufficient information about the cost of services received before receiving each care.

The Legal Landscape of Healthcare Access in Rural America

The healthcare system in the United States ought to provide its citizens with unhindered access to high quality medical care as well as equitable treatment and coverage. Legislation to advance access to healthcare, such as the creation of the Medicare and Medicaid programs in 1965 and the Affordable Care Act in 2008, have been appropriate steps forward in achieving these goals, but obstacles to healthcare access still persist for many Americans. Healthcare access is hindered by foundational problems, such as a large uninsured population, inadequate infrastructure and facilities, and high costs for services. In rural communities, these problems assume different social and economic contexts and thus require their own separate evaluation. Rural Americans currently lack effective access to healthcare, despite existing policies aimed at improving access by making healthcare more affordable. In this article, I will explain different facts of the discussion revolving around rural healthcare access and analyze specific problems in the area. There are three policy directives that are essential to the expansion of rural healthcare access: public private partnerships, loan forgiveness for doctors serving at critical access hospitals, and expansion of the telehealth network. These avenues expand rural healthcare access, minimize government expenditure, and maximize public benefits.

How a System Is Closing the Evidence-Based Data Management Gap.

To translate raw data into information that is understandable and actionable, healthcare leaders must leverage decision-making tools that can drive strategic innovation, improve processes, and shape the future of healthcare. Continuous changes in healthcare delivery require constant monitoring of an expanding range of data. Population demographics, psychographics, and availability of care all must be considered, as well as provider practice patterns, patient utilization, clinical and service quality, costs, and many other key variables over time. RWJBarnabas Health is navigating significant changes in its approach to managing data. A unified operating model is driving standardization, continuous quality improvement, and cost reductions across the system. The solution is based on an electronic health record system designed to meet the needs of the entire system, an array of carefully selected external data sources, and a business intelligence tool to enable leaders to quickly draw insights from all the available data.

#1377 Evaluation of state-wide health system implementation of renal supportive care shows substantial net benefits

Abstract Background and Aims In 2016, the New South Wales (NSW) Health system implemented a service to make the principles and practice of palliative medicine comprehensively available to patients receiving chronic kidney disease (CKD) care across NSW. Summative evaluation of the economic value that this multi-disciplinary State-wide RSC service provided following implementation was prospectively planned in the domains of patient experience and economic value. This abstract reports the first cost-benefit analysis of a RSC service. Method De-identified patient-level data was extracted from the NSW Renal Supportive Care Register (a linked dataset comprising admitted patient, non-admitted patient, emergency department episodes and death registrations). Data was compared between 2015/16, prior to implementation of the State-wide RSC service; and 2018/19, following settled operation of the service. A cost-benefit analysis model was constructed to estimate the economic value of the RSC service between 2015/16 and 2018/19; and the projected value to 2029/30 under different scenarios. Multivariate Cox regressions were estimated to measure survival benefits, and a polynomial regression model was employed to estimate the impact of RSC on the share of patients receiving dialysis. Results Considering the actual impact of the NSW RSC service; in 2015/16, 5% (n = 443) of all ESKD patients, (defined as receiving dialysis >3 months, non-dialysis conservative care or in receipt of a functioning transplant) received any RSC service. By 2018/19, 16% (n = 1460) of all ESKD patients had received RSC within NSW. The proportion of patients receiving RSC from a non-dialysis conservative care or dialysis context remained stable between 2015/16 and 2018/19 at 41% and 29% respectively. Patients receiving RSC were estimated to have increased survival by 3-21 weeks, depending on patient characteristics, compared to the scenario of no RSC service. Considering the projected value of ongoing RSC services; scenarios with different assumptions were modelled. Assuming that the proportion of patients receiving different ESKD modalities and the costs of care remained stable, the RSC service would deliver a net financial benefit to the commissioning health system (avoided costs of service minus RSC costs) of ${\$}$109 million Australian Dollars (AUD), with a return on investment of 212%, compared to the scenario of no RSC service. When the economic value for the whole NSW community from increased survival benefit was included, the projected value was ${\$}$275 million AUD, with return on investment of 535%. The projected economic value of RSC was modelled under scenarios of increasing access to the service by ESKD patients (Figure). Increasing RSC access from the achieved 16% to 20% of ESKD patients was projected to deliver maximal economic value, with a 3% fall in ESKD patients receiving dialysis, increasing survival benefit (${\$}$221 million AUD) and economic value ${\$}$94 million AUD. As access to RSC expands further, modelling indicates that additional dialysis substitution becomes less likely but benefits still accrue from survival up to a maximum viable rollout of 50% of the ESKD population receiving RSC, when survival benefits plateau. Conclusion Economic evaluation of this implementation of the Statewide RSC service across NSW Health shows it has been associated with both a net economic benefit and survival benefits four years after implementation. It is projected to provide an economic value of ${\$}$275 million AUD over ten years, which would increase with greater participation of ESKD patients suitable for RSC.

A novel solid waste instance creation for an optimized capacitated vehicle routing model using discrete smell agent optimization algorithm

This paper presents an optimal vehicle routing model for an efficient waste collection process using the Ogun State Waste Management Agency (OGWAMA) as a case study. Just like in many cases, the current manual predetermined routing method used by OGWAMA is inefficient and contributes to excessive fuel usage. These challenges, in addition to the small instances reported in most literature, inspire this research to propose an improved routing scheme that takes into account real-time costs and eventually develops a novel instance based on OGWAMA's operation mode. The developed model was optimized using a new discrete smell agent optimization (SAO) algorithm and compared to firefly algorithm (FA) and particle swarm optimization (PSO). The SAO outperformed FA and PSO, achieving 3.92 % and 19.38 % improvements in service cost (SC) and 2.65 % and 14.96 % improvements in total travel distance (TTD), respectively. The convergence rates of the algorithms were also compared; using the Optimized Depot (OD) techniques and results shows the acceptability of the proposed approaches.

Levelling up health in the early years: A cost-analysis of infant feeding and healthcare.

Although breastfeeding is recommended as the optimal form of nutrition in the first six months, it is not sustained as the predominant mode of feeding infants in Scotland. This study estimated the impact of infant feeding choices on primary and secondary healthcare service costs in a 13-year birth cohort. Using linked administrative datasets, in a retrospective cohort design of 502,948 singletons born in Scotland between 1997 and 2009, we estimated the cost of GP consultations and hospital admissions by area deprivation and mode of infant feeding up to 6-8 weeks for ten common childhood conditions from birth to 27 months. Additionally, we calculated the potential healthcare savings if all infants in the cohort had been exclusively breastfed at 6-8 weeks. Discounting of 1.5% was applied following current health economic conventions and 2009/10 used as the base year. Over the study period, the estimated cost of hospital admissions in the cohort was £111 million and £2 million for the 2% subset of the cohort with primary care records. Within each quintile of deprivation, exclusively breastfed infants used fewer healthcare services and incurred lower costs compared to infants fed (any) formula milk. At least £10 million of healthcare costs may have been avoided if formula-fed infants had been exclusively breastfed within the first 6-8 weeks of birth. This study using a representative birth cohort demonstrates how breastmilk can promote equitable child health by reducing childhood illness and healthcare utilisation in the early years.

Optimal Scheduling of Grid-side Flexibility Resources and Auxiliary Service Cost Allocation Model Considering New Energy Penetration

Optimal Scheduling of Grid-side Flexibility Resources and Auxiliary Service Cost Allocation Model Considering New Energy Penetration

Bridging operations research and machine learning for service cost prediction in logistics and service industries

AbstractOptimizing shared resources across multiple clients is a complex challenge in the production, logistics, and service sectors. This study addresses the underexplored area of forecasting service costs for non-cooperative clients, which is essential for sustainable business management. We propose a framework that merges Operations Research (OR) and Machine Learning (ML) to fill this gap. It begins by applying the OR model to historical instances, optimizing resource allocation, and determining equitable service cost allocations for each client. These allocations serve as training targets for ML models, which are trained using a combination of original and augmented client data, aiming to reliably project service costs and support competitive, sustainable pricing strategies. The framework’s efficacy is demonstrated in a reverse logistics case study, benchmarked against two traditional cost estimation methods for new clients. Comparative analysis shows that our framework outperforms these methods in terms of predictive accuracy, highlighting its superior effectiveness. The integration of OR and ML offers a significant decision-support mechanism, improving sustainable business strategies across sectors. Our framework provides a scalable solution for cost forecasting and resource optimization, marking progress toward a circular, sustainable economy by accurately estimating costs and promoting efficient operations.

Comparing Mobile-Based to Group-Based Education for Weight Reduction in a Developing Country: A Randomized Study.

This study compared the impact of Short Message Service (SMS)-based education with traditional group-based education and the control group on body mass index, weight, and lifestyle in obese and overweight patients in a limited-resource country. It also compared the direct financial costs between the two intervention groups. In this controlled randomized educational study, 90 overweight or obese adults from four family physician clinics in Shiraz, Iran were randomly allocated to three training groups: SMS-based education, group-based education, and a control group. The participants' weight, body mass index (BMI), and waist circumference were measured at baseline, and the Physical Activity Scale questionnaire was completed. Group-based training was conducted in 1-hour weekly sessions. The SMS group received a text message each morning. The control group received routine care from a family physician. The intervention lasted 12 weeks. All participants were re-examined for the studied variables. Additionally, the direct costs were estimated, calculated, and compared. The mean weight, BMI, and waist circumference changed significantly after 3 months compared to baseline in each group. The mean weight change differed significantly among the three groups (P-value=0.04), and the mean BMI changes were near significant (P-value=0.06). A post hoc comparison of changes in weight and BMI showed a significant difference between the control and SMS groups. SMS education incurred much lower costs for patients and healthcare services than group-based education. The study showed that SMS is an effective and cost-saving educational method for weight loss compared to group-based education, especially in developing countries.

How consumers evaluate costs in complex services: the case of mutual fund fees

PurposeIn modern societies, consumer well-being is dependent on choices regarding complex services, such as investments, health care, insurance and lending. However, evaluating costs of such services is often difficult for consumers due to a combination of limited cognitive resources and complexity of the service. The purpose of this study is to empirically examine to what extent three specific consequences of complexity influence consumer tendencies to make mistakes when evaluating the costs (or price) of complex services.Design/methodology/approachThree studies were conducted (survey: n = 153, experiment: n = 332 and conjoint analysis: n = 225), all focusing on how consumers evaluate costs in the complex mutual fund setting.FindingsThe authors find that consumers struggle with estimating and using cost information in decision-making in the complex services setting. Consumers of complex services frequently underestimate the costs over the long-term, may see costs as a signal of service quality and are susceptible to influence from presentation formats when evaluating costs.Research limitations/implicationsThe study investigates mutual funds, which is one example of a complex service. In order to get a full picture of how consumers deal with costs in complex setting, future research needs to expand this focus to other types of complex services.Practical implicationsThe results have implications for both marketers of complex services and policymakers. For marketers, this paper highlights that competing with a low-cost strategy may be difficult in the complex services setting as consumers may lack the ability to actually evaluate what they pay over the long term. For policymakers, increased simplification of prices may be an attractive option. However, it is important that this simplification is done in a way that increases the possibility to compare prices.Originality/valueAs complexity influences several aspects of decision-making, an understanding of how consumers evaluate costs in complex settings is dependent on taking a multidimensional research approach. This paper makes a novel contribution to the literature on pricing by showing that consumers struggle with multiple aspects when evaluating costs in complex contexts. Understanding these effects is important to policy, as well as to research on the cognitive value of simplicity that is currently gaining traction in marketing research.

Generative AI Applications in Helping Children with Speech Language Issues

This paper reports how generative AI can help children with specific language impairment (SLI) issues by developing an AI-assisted tool to support children with challenges in phonological development in English, especially children with English as the secondary language in the United States. Children from bilingual families often experience challenges in developing proficiency in English pronunciation and communication, which has been exacerbated by remote learning during the pandemic and led to learning loss. School-aged children with speech problems require timely intervention because children with language disorders find it difficult to communicate with others, leading to social isolation and academic difficulties. The needed intervention is often delayed due to the high cost of speech services and the shortage of Speech and Language Pathologists (SLPs). Individuals with a history of SLI have an increased risk of unemployment. An AI-assisted Phonological Development (AI-PD) tool was prototyped, aiming to alleviate these challenges by assisting caregivers in evaluating children's phonological development, assisting SLPs in lesson preparation, and mitigating the severe shortage of SLPs.